EP1842064A4 - Biomarqueurs ischemiques et utilisation associee pour prevoir des evenements neurologiques indesirables dus a une intervention chirurgicale - Google Patents

Biomarqueurs ischemiques et utilisation associee pour prevoir des evenements neurologiques indesirables dus a une intervention chirurgicale

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Publication number
EP1842064A4
EP1842064A4 EP06719248A EP06719248A EP1842064A4 EP 1842064 A4 EP1842064 A4 EP 1842064A4 EP 06719248 A EP06719248 A EP 06719248A EP 06719248 A EP06719248 A EP 06719248A EP 1842064 A4 EP1842064 A4 EP 1842064A4
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EP
European Patent Office
Prior art keywords
surgery
nmda receptor
risk
patient
neurological event
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Granted
Application number
EP06719248A
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German (de)
English (en)
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EP1842064A1 (fr
EP1842064B1 (fr
Inventor
Svetlana A Dambinova
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CIS Biotech Inc
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CIS Biotech Inc
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Publication of EP1842064A4 publication Critical patent/EP1842064A4/fr
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Classifications

    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
    • G01N33/6893—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids related to diseases not provided for elsewhere
    • G01N33/6896—Neurological disorders, e.g. Alzheimer's disease
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
    • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
    • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
    • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
    • G01N33/6893—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids related to diseases not provided for elsewhere
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/28—Neurological disorders
    • G01N2800/2871—Cerebrovascular disorders, e.g. stroke, cerebral infarct, cerebral haemorrhage, transient ischemic event
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/32—Cardiovascular disorders

Definitions

  • the present invention relates to methods for predicting the risk of adverse neurological events from surgery.
  • the present invention relates to methods of testing for NR2 peptides and antibodies in the blood of patients scheduled for surgery, and to methods of using such test results to predict the likelihood of a stroke, transient ischemic attack (TIA) or other ischemic induced episode in a patient from surgery.
  • This testing is particularly useful in patients with preexisting cardiovascular disorders, cerebrovascular disorders, hypertension, diabetes, or carotid bruit, who are more likely to suffer from adverse neurological events from surgery, but whose risk from the surgery is not fully known.
  • the diagnostic and prognostic capabilities of this testing promise to reduce morbidity and mortality in the operating room, and to improve the management of cardio- and cerebrovascular patients assigned to surgery.
  • Strokes are either occlusive (due to blockage of a blood vessel) or hemorrhagic (due to bleeding from a vessel), and both can result in insufficient blood supply to the brain resulting in a condition known as ischemia.
  • Focal brain injury is different than the global anoxic brain damage that often occurs after cardiac arrest or hypoperfusion (Graham SH, Chen J. J Cereb Blood Flow 2001; 21:99-109).
  • an ischemic core develops that is typically surrounded by a penumbra zone of surviving cells. These surviving cells prevent (or at least delay) expansion of the infarct and the amount of brain damage (Deshpande J, et al. Exp Brain Res 1992; 88: 91-105; Matsui T, et al. J Cereb Blood Flow Metab 2002; 22:711-722).
  • SlOOB is a calcium-regulating protein found primarily in glia and Schwann cells.
  • CRP C- reactive protein
  • NMDA N-methyl-D-aspartate receptor peptides and their antibodies have been proposed as biomarkers of neurotoxicity underlying cerebral ischemia and stroke (Dambinova SA, et al. Stroke 2002; 33:1181-1182; Dambinova SA, et al. Clin Chem 2003; 49: 1752-1762).
  • the NMDA receptor is unique to the brain. With neuronal death or ischemia, peptide fragments of the NMDA receptor break off and appear in the bloodstream and generate an antibody response. The peptide fragment and antibody can both be detected in blood samples (Dambinova SA, et al. Stroke 2002).
  • NMDA peptide and/or antibodies that correlate with the amount of brain damage on brain scans (MRI) and the patient's neurocognitive status (Dambinova SA, et al. Clin Chem 2003; 49:1752-1762).
  • Cerebral damage due to cardiac surgery is currently assessed retrospectively by comparing preoperative and postoperative clinical and neuropsychological evaluations, or using imaging techniques (CT or MRI) to detect morphological changes.
  • CT or MRI imaging techniques
  • the neuropsychological assessment requires time, expert staff and patient cooperation.
  • neuroimaging particularly MRI is very costly and may be stressful and risky for the patients in the postoperative period.
  • a biochemical marker able to detect cerebral injury and predict further cerebral injury would have considerable practical value.
  • One object of the present invention to accurately predict the risk of adverse neurological events from a planned surgery, including transient ischemic attack (TIA), stroke, and neurocognitive dysfunction, using biomarkers that can be detected in human blood or other biological fluids before the surgery occurs.
  • TIA transient ischemic attack
  • stroke stroke
  • neurocognitive dysfunction using biomarkers that can be detected in human blood or other biological fluids before the surgery occurs.
  • Another object of the present invention is to evaluate the risk of ischemia-induced adverse neurological events from a planned surgery in patients at particular risk for such adverse events, including patients with preexisting cardiovascular or cerebrovascular damage or chronic ischemic stress, or diabetes.
  • Still another object of the invention is to enable a more effective selection of interventional strategies for reducing the risk of adverse neurological events from surgery, including monitoring regimens and neuroprotective therapy against damage caused by cerebral ischemia, before, during and after a surgery.
  • Methods and kits are provided for assessing the risk of a patient suffering an adverse neurological event from surgery based on the presence and amount of NMDA receptor peptides and antibodies in the bloodstream of the patient.
  • Clinically predetermined cut-offs for NMDA receptor peptides and antibodies have allowed us to demonstrate the high-performance characteristics and clinical utility of these peptide and antibody tests for assessing the risk of adverse neurological events, including TIA and stroke, in adult patients before surgery.
  • Analyses of pre- and post-operative NMDA peptide and antibody distributions have shown that these markers have high predictive value for neurological complications alone and when combined with MMSE (Mini-Mental Status Exam) component scores. Diagnostic and therapeutic methods for managing and reducing such risk based on the results of this testing have also been developed.
  • Blood levels of the NR2A and NR2B subunits of the NMDA receptor, especially peptide fragments from the N-terminal domain of the NR2A and NR2B subunits, are particularly preferred in the methods of the present invention, and remarkably accurate for predicting the likelihood of adverse neurological events from surgery.
  • the methods were able to predict 96.2% of the patients who would suffer a stroke or TIA when greater than 2.0 ng/ml of antibody was present in patients' blood serum, and 95.6% of the patients who would not suffer a stroke or TIA when less than 2.0 ng/ml of antibodies was present in patients' blood serum.
  • CRP C-reactive protein
  • the invention provides a method for aiding in the assessment of the risk of stroke in an apparently healthy human subject prior to surgery comprising: (a) obtaining a test sample from the human subject; (b) analyzing the test sample for the presence or amount of an NR2 antigen of an NR2 antibody, or a combination thereof; and comparing the result of step (b) with a corresponding reference amount of an NR2 antigen or NR2 antibody, or a combination thereof, wherein the corresponding reference amount is derived from a population of apparently healthy human subjects.
  • the invention further provides monitoring regimens and neuroprotective therapies for managing or reducing such risk.
  • monitoring regimens and neuroprotective therapies for managing or reducing such risk.
  • the patient could take various drugs known to benefit the cardiovascular system and reduce the risk of stroke, including various antiplatelet agents, anticoagulants, lipid lowering agents, blood pressure medications (if high blood pressure is observed), and surgical intervention.
  • a strict monitoring regimen could be instituted in which NR2 levels are monitored one or more additional times, including immediately before the surgery, during the surgery, or immediately after the surgery.
  • An NMDA receptor is one of a family of ligand-gated ion channels that bind preferentially to N-methyl-D-aspartate and that mediate the vast majority of excitatory neurotransmission in the brain (Dingledine R. et al., Pharmacol Rev. 1999 Mar;51(l):7-61.).
  • the receptors include several subunits reported in the literature as NRl, NR2A, NR2B, NR2C, NR2D and NR3A, that perform distinct pharmacological functions. GenEMBL Accession Nos.
  • NRl X58633
  • NR2A U09002
  • NR2B U28861
  • WO 02/12892 to Dambinova A "cerebral" NMDA receptor refers to a receptor that is present in the brain, as opposed to an NMDA receptor that is only present in an organ of the human body outside of the brain.
  • An NMDA receptor peptide refers to a full length NMDA receptor protein, a peptide fragment of the naturally occurring full length NMDA receptor, or an analogue, derivative, fragment or recombined (a/k/a recombinant) plurality of fragments thereof.
  • An NR2 peptide includes the full length NR2A, NR2B, NR2C and NR2D subunits, in addition to fragments, analogs, derivatives, and recombined fragments thereof.
  • An NR2A, NR2B, NR2C, or NR2D peptide means the full length naturally occurring NR2A, NR2B, NR2C or NR2D peptide subunits, or a fragment, analog, derivative or recombined fragments thereof.
  • the N-terminal domain of the NR2A and NR2B peptides refers to the amino acid N-terminal domain fragment of the full length NR2A and NR2B subunits, or a fragment, analog, derivative or recombined fragments thereof, as described in WO 02/12892 to Dambinova.
  • a circulating NMDA receptor peptide refers to an NMDA receptor peptide that has crossed the blood brain barrier into the systemic blood circulation, and fragments thereof generated in the blood stream.
  • a particularly preferred circulating NMDA receptor peptide is one which comprises one or more fragment sequences that are common to both NR2A and NR2B subunits.
  • the peptide may include one such sequence, or 2 or more such sequences that are present at discreet locations on the native NR2 peptide backbone, and recombined into one sequential fragment either in vivo or vitro.
  • an "analogue" of a peptide means a peptide that contains one or more amino acid substitutions, deletions, additions, or rearrangements.
  • an amino acid belonging to a grouping of amino acids having a particular size or characteristic such as charge, hydrophobicity, and hydrophilicity
  • an analogue of an NMDA peptide is useful in the present invention if it includes amino acid substitutions, deletions, additions or rearrangements at sites such that antibodies raised against the analogue are still specific against the NMDA peptide.
  • an NMDA analogue refers to a sequence that has at least 80% amino acid identity with naturally occurring NMDA, although it could also contain at least 85%, 90%, or 95% identity.
  • Amino acid identity is defined by an analogue comparison between the analogue and naturally occurring NMDA. The two amino acid sequences are aligned in such a way that maximizes the number of amino acids in common along the length of their sequences; gaps in either or both sequences are permitted in making the alignment in order to maximize the number of common amino acids.
  • the percentage amino acid identity is the higher of the following two numbers: (1) the number of amino acids that the two peptides have in common with the alignment, divided by the number of amino acids in the NMDA analogue, multiplied by 100, or (2) the number of amino acids that the two peptides have in common with the alignment, divided by the number of amino acids in naturally occurring NMDA peptide, multiplied by 100.
  • NMDA derivatives include naturally occurring NMDA and NMDA analogues and fragments thereof that are chemically or enzymatically derivatized at one or more constituent amino acids, including side chain modifications, backbone modifications, and N- and C- terminal modifications, by for example acetylation, hydroxylation, methylation, amidation, phosphorylation or glycosylation.
  • the term also includes NMDA salts such as zinc NMDA and ammonium NMDA.
  • a protein or peptide is measured "directly" in the sense that the protein or peptide is itself measured in the biological sample, as opposed to some other indirect measure of the protein or peptide such as autoantibodies to the protein or peptide, other peptide fragments from the same protein or subunit, or cDNA associated with the expression of the protein or peptide.
  • antibody is synonymous with “immunoglobulin.”
  • antibody includes both the native antibody, monoclonally generated antibodies, polyclonally generated antibodies, recombinant DNA antibodies, and biologically active derivatives of antibodies, such as, for example, Fab', F(ab') 2 or Fv as well as single-domains and single-chain antibodies.
  • a biologically active derivative of an antibody is included within this definition as long as it retains the ability to bind the specified antigen.
  • an NR2 antibody has the ability to bind at least one NR2 peptide. Discussion
  • the invention provides a method for aiding in the assessment of the risk of stroke in an apparently healthy human subject prior to surgery comprising: (a) obtaining a test sample from the human subject; (b) analyzing the obtained test sample for the presence or amount of an NR2 antigen of an NR2 antibody, or a combination thereof; and comparing the result of step (b) with a corresponding reference amount of an NR2 antigen or NR2 antibody, or a combination thereof, wherein the corresponding reference amount is derived from a population of apparently healthy human subjects.
  • the invention provides a method for predicting an adverse neurological event from surgery comprising: (a) providing a human patient scheduled for surgery; (b) measuring an initial level of circulating cerebral NMDA receptor peptides from a biological fluid in said patient; and (c) correlating said level to a risk for suffering an adverse neurological event from surgery.
  • NMDA receptor peptides or antibodies When a patient is tested and has dangerous levels of NMDA receptor peptides or antibodies in his or her bloodstream, it is preferred to test the patient several more times before surgery and during surgery. In addition, because patients often do not suffer an adverse neurological event until shortly after the surgery, it is preferred to test these patients one or more additional times after surgery, within one or more of the following time periods: one hour, three hours, six hours, twelve hours, twenty four hours, three days, seven days, or thirty days.
  • the invention further includes (a) measuring a subsequent level of circulating cerebral NMDA receptor peptides in said patient after said surgery; (b) determining whether there is a difference between said initial and subsequent levels; and (c) correlating a difference between said initial and subsequent levels to an adverse neurological event which is either occurring or likely to occur in the near future.
  • the methods can be performed on adults or children scheduled for surgery, and in a particularly important embodiment are performed in neonatal patients or infants who are at particular risk for neurological sequelae.
  • the method is particularly useful when evaluating patients who are already predisposed to suffering a neurological event, such as patients with a history of diabetes, atherosclerosis, high blood pressure, or a previous suspected or confirmed TIA or stroke.
  • the methods can also be used in conjunction with MMSA testing, before surgery, to predict the risk of an adverse neurological event. Preoperative decreased MMSA component scores for orientation, attention and recall have been associated with confusion and cerebrovascular events shortly after surgery.
  • the types of neurological events that can be predicted by the current invention are generally those induced by cerebral ischemia, and especially ischemic events that are caused by insufficient supplies of oxygen to the brain (as opposed to hemmorhagic events that occur when blood vessels are ruptured in the brain). These events can be focalized in a particular region of the brain, as occurs in stroke or TIA, or global, as occurs in delirium.
  • the adverse neurological event may thus be characterized by confusion or may be diagnosed as a TIA or ischemic stroke. Oxygen supplies can be compromised due to the health condition of the patient (as in certain blood disorders such as anemia), but more commonly will be caused by the surgical event.
  • the adverse neurological event is said to be "from” the surgery if the event occurs during surgery, or within thirty days after the surgery is completed, although the resulting adverse event could also be identified in a time frame of seven days, three days, two days or one day, if desired.
  • the prognostic methods of the present invention can predict the risk of adverse neurological events from any type of surgery, although traumatic surgeries that temporarily slow or halt the flow of oxygen to the brain will benefit most.
  • the method should be performed before any cardiovascular procedure that occludes or blocks normal blood circulation, that results in intraoperative micro-or macro-emboli, abnormal cerebral perfusion, reperfusion injury, or an inflammatory or neruhumoral response.
  • the invention is especially useful in predicting the occurrence of adverse neurological events when a cardiopulmonary bypass is performed.
  • the testing methods can be performed based on measurements of any circulating NMDA receptor peptide, and they can be performed using any direct or indirect measurement technique.
  • the levels of circulating peptides can be measured by an indirect measure of antibodies to the peptides, CDNA expression encoding the peptides, or by measuring the peptides themselves. Therefore, in one embodiment the invention provides a method wherein said level is measured by contacting said biological fluid with an immobilized antibody or fragment thereof (i.e., one which is bound to a carrier such as a plate or bead or small particle), and directly measuring the level of one or more circulating cerebral NMDA receptor peptides.
  • an immobilized antibody or fragment thereof i.e., one which is bound to a carrier such as a plate or bead or small particle
  • the invention provides a method wherein said level is measured by contacting said biological fluid with an immobilized cerebral NMDA receptor peptide, and measuring the level of antibody that binds to said immobilized peptide.
  • various subunits and fragments of the NMDA receptor may preferentially be measured.
  • the method is preferably performed by measuring NR2A peptides or NR2B peptides, and is even more preferably performed by measuring both.
  • the method is performed by measuring one or more peptide sequences that are common to the native NR2A and NR2B sequences, one or more peptide sequences that are common to the N-terminal domain of native NR2A and NR2B sequences, or antibodies thereto.
  • circulating peptides that comprise 2,7 and 14 kDa fragments of the N-terminal domain of the NR2A and NR2B subunits of a cerebral NMDA receptor are measured in the methods of the present invention.
  • the method can be performed using practically any biological fluid where circulating cerebral NMDA receptors, or markers of such receptors, are expressed or found, including blood, urine, blood plasma, blood serum, cerebrospinal fluid, saliva, perspiration or brain tissue.
  • the biological fluid is plasma or serum, and in an even more preferred embodiment the plasma or serum is diluted to a ratio of about 1:50.
  • a risk assessment is made based on a predetermined cutoff of peptide levels.
  • levels of NR2A/B N-terminal domain antibodies in plasma or serum that are greater than 2.0, 1.8, 1.5, or 1.0 ng/ml, or levels of NMDA peptides that correspond to NR2A/B N-terminal domain circulating peptides of greater than 200, 100, or 50 pg/ml, are remarkably predictive of an adverse neurological event in a patient undergoing surgery.
  • levels of NR2A/B N- terminal domain antibodies in plasma or serum that are less than 2.0, 1.8, 1.5, or 1.0 ng/ml, or levels of NMDA peptides that correspond to NR2A/B N-terminal domain circulating peptides of less than 200, 100, or 50 pg/ml, are remarkably predictive that an adverse neurological event will not occur during surgery.
  • a preferred antibody cutoff is 2.0 ng/ml.
  • various regimens can be implemented to decrease the risk of an adverse neurological event should surgery proceed as scheduled.
  • the method might further include, if the patient is at risk for suffering an adverse neurological event from surgery, (i) administering neuroprotective therapy to said patient, or (ii) implementing a monitoring program for monitoring the risk or occurrence of an adverse neurological event.
  • Neuroprotective therapies include drug regimens, such as antiplatelet, anticoagulant, lipid- lowering and blood pressure lowering drugs.
  • the method could further comprise, if the patient is at risk for suffering an adverse neurological event from surgery, optionally analyzing said patient for new infarction area defined by MRI, and performing neurosurgery or vascular surgery on said patient, such as carotid endarterectomy, direct endarterectomy, angioplasty and stent placement, extracranial-intracranial bypass, and vertebral artery transposition.
  • neurosurgery or vascular surgery such as carotid endarterectomy, direct endarterectomy, angioplasty and stent placement, extracranial-intracranial bypass, and vertebral artery transposition.
  • the method can be performed using any number of known diagnostic techniques, including immunoprecipitation (IP), indirect immuno-fluorescence (IIF), immunodot and immunoblotting (IB) (Western Blot), direct or indirect enzyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA), counter-immuno-electrophoresis (CIE), flow cytometry (FC), latex agglutination, lateral flow, fluorescence polarization assay, or microarray.
  • IP immunoprecipitation
  • IIF indirect immuno-fluorescence
  • IB immunodot and immunoblotting
  • ELISA direct or indirect enzyme-linked immunosorbent assay
  • RIA radioimmunoassay
  • CIE counter-immuno-electrophoresis
  • FC flow cytometry
  • latex agglutination lateral flow
  • fluorescence polarization assay or microarray.
  • the invention is practiced using an immobilized solid phase for capturing and measuring
  • the invention thus provides a method for predicting an adverse neurological event from surgery comprising: (a) providing a human patient scheduled for surgery; (b) contacting a biological sample from said patient with an immobilized solid phase comprising a NR2 peptide or NR2 antibody, for a time sufficient to form a complex between said NR2 peptide or said NR2 antibody and NR2 antibody or NR2 peptide in said biological sample; (c) contacting said complex with an indicator reagent attached to a signal - generating compound to generate a signal; (d) measuring the signal generated; (e) correlating to signal generated to the level of saidNR2 peptide orNR2 antibody in said sample; and (f) correlating the level of said NR2 peptide or NR2 antibody in said sample to said risk for an adverse neurological event.
  • the indicator reagent comprises chicken anti-human or anti-human IgG attached to horseradish peroxidase.
  • the solid phase is a polymer matrix. More preferably, the polymer matrix is polyacrylate, polystyrene, or polypropylene. In one preferred embodiment the solid phase is a microplate. In another preferred embodiment, the solid phase is a nitrocellulose membrane or a charged nylon membrane.
  • the method is performed using agglutination.
  • the invention provides a method for predicting an adverse neurological event from surgery comprising: (a) providing a human patient scheduled for surgery; (b) contacting a biological sample from said patient with an agglutinating carrier comprising a NR2 peptide or NR2 antibody, for a time sufficient to form an agglutination complex between said NR2 peptide or said NR2 antibody and NR2 antibody or NR2 peptide in said biological sample; (c) generating a signal from the agglutination; (d) correlating said signal to said levels of one or more markers of NR2 peptide; and (e) correlating the level of said NR2 peptide or NR2 antibody in said sample to said risk for an adverse neurological event.
  • the "sufficient time” is less than 30, 20, 15 or even 10 minutes.
  • Latex agglutination assays have been described in Beltz, G. A. et al., in Molecular Probes: Techniques and Medical Applications, A. Albertini et al., eds., Raven Press, New York, 1989, incorporated herein by reference.
  • antibody raised against a particular biomarker is immobilized on latex particles.
  • a drop of the latex particles is added to an appropriate dilution of the serum to be tested and mixed by gentle rocking of the card. With samples lacking sufficient levels of the biomarkers, the latex particles remain in suspension and retain a smooth, milky appearance. However, if biomarkers reactive with the antibody are present, the latex particles clump into visibly detectable aggregates.
  • An agglutination assay can also be used to detect biomarkers wherein the corresponding antibody is immobilized on a suitable particle other than latex beads, for example, on gelatin, red blood cells, nylon, liposomes, gold particles, etc.
  • a suitable particle other than latex beads for example, on gelatin, red blood cells, nylon, liposomes, gold particles, etc.
  • the presence of antibodies in the assay causes agglutination, similar to that of a precipitation reaction, which can then be detected by such techniques as nephelometry, turbidity, infrared spectrometry, visual inspection, colorimetry, and the like.
  • latex agglutination is employed generically herein to refer to any method based upon the formation of detectable agglutination, and is not limited to the use of latex as the immunosorbent substrate. While preferred substrates for the agglutination are latex based, such as polystyrene and polypropylene, particularly polystyrene, other well-known substrates include beads formed from glass, paper, dextran, and nylon.
  • the immobilized antibodies may be covalently, ionically, or physically bound to the solid-phase immunoadsorbent, by techniques such as covalent bonding via an amide or ester linkage, ionic attraction, or by adsorption. Those skilled in the art will know many other suitable carriers for binding antibodies, or will be able to ascertain such, using routine experimentation.
  • polyclonal antisera or monoclonal antibodies can be made using standard methods.
  • a mammal e.g., a mouse, hamster, or rabbit
  • an immunogenic form of the peptide preferably the NR2A and/or NR2B receptor, an antigenic determinant of the NR2A and/or NR2B receptor, or an analogue or derivative thereof
  • Techniques for conferring immunogenicity on a peptide include conjugation to carriers or other techniques well known in the art.
  • the peptide can be administered in the presence of adjuvant.
  • the progress of immunization can be monitored by detection of antibody titers in plasma or serum.
  • Standard ELISA or other immunoassay procedures can be used with the immunogen as antigen to assess the levels of antibodies.
  • antisera can be administered and, if desired, polyclonal antibodies isolated from the sera.
  • antibody producing cells can be harvested from an immunized animal and fused with myeloma cells by standard somatic cell fusion procedures thus immortalizing these cells and yielding hybridoma cells.
  • Such techniques are well known in the art, (e.g., the hybridoma technique originally developed by Kohler and Milstein (Nature 256, 495-497 (1975)) as well as other techniques such as the human B-cell hybridoma technique (Kozbor et al., Immunol. Today 4, 72 (1983)), the EBV-hybridoma technique to produce human monoclonal antibodies (Cole et al. Monoclonal Antibodies in Cancer Therapy (1985) Allen R.
  • Hybridoma cells can be screened immunochemically for production of antibodies specifically reactive with the peptide and the monoclonal antibodies can be isolated. Therefore, the invention also contemplates hybridoma cells secreting monoclonal antibodies with specificity for NR2A or NR2B NMDA proteins or fragments thereof as described herein.
  • the method is practiced using a kit that has been calibrated at the factory based upon antibodies or peptides purified from human blood. Therefore, in another embodiment the invention is practiced under the following conditions: (a) NR2 antibody or peptide levels in said biological fluid are measured using a diagnostic kit; (b) said diagnostic kit comprises bound NR2 peptides or antibodies; and (c) said kit is manufactured against an antibody or peptide standard comprising a fraction of immunoglobulins G or peptides purified from human blood.
  • the method can be practiced using commercially available chemiluminescence techniques.
  • the method could employ a two-site sandwich immunoassay using direct chemiluminescent technology, using constant amounts of two monoclonal antibodies.
  • the first antibody in a fluid reagent, could be an acridinium ester labeled monoclonal mouse anti-human NMDA receptor peptide BNP (F(ab') 2 fragment specific to a first portion of the peptide.
  • the second antibody in the solid phase, could be a biotinylated monoclonal mouse anti-human antibody specific to another portion of the peptide, which could be coupled to streptavidin-functionalized magnetic particles.
  • An immuno-complex would be formed by mixing a patient sample and the two antibodies. After any unbound antibody conjugates are washed away, the chemiluminescence of the immuno-complex signal could then be measured using a luminometer.
  • the immunosorbent of the present invention for measuring levels of autoantibody can be produced as follows.
  • a fragment of the receptor protein is fixed, preferably by covalent bond or an ionic bond, on a suitable carrier such as polystyrene or nitrocellulose.
  • a suitable carrier such as polystyrene or nitrocellulose.
  • the standard polystyrene plate for immunological examinations is employed, it is first subjected to the nitration procedure, whereby free nitrogroups are formed on the plate surface, which are reduced to amino groups and activated with glutaric dialdehyde serving as a linker.
  • the thus- activated plate is incubated with about 2 to 50 nM of the target peptide for the purpose of chemically fixing the respective immunogenic fragment of the receptor protein for a time and at a temperature sufficient to assure fixation (i.e. for about 16 hours at 4°C).
  • the immunosorbent by fixing the respective fragment of the receptor protein on nitrocellulose strips by virtue of ionic interaction.
  • the respective fragment of the receptor protein isolated from the mammals' brain is applied to nitrocellulose and incubated for 15 min at 37°C. Then nitrocellulose is washed with a 0.5 % solution of Tween-20, and the resultant immunosobent is dried at room temperature and stored in a dry place for one year period.
  • a preferred NR2 peptide test is a latex agglutination immunoassay for the qualitative determination of NR2 peptide in the blood. Blood samples are mixed with antibody coupled to latex beads and agglutination is visually detected within 10 minutes. After addition of a blood sample to the sample port of the test device, the red blood cells are separated from plasma by a filter. A predetermined quantity of plasma moves by capillary action into a reaction chamber, where it reacts with latex reagent (antibody-coated latex beads) to form complexes that can be detected visually.
  • the test uses calibrators set from 100-5000 pg/ml and standards with "low” ( ⁇ 200pg/ml) and "high” (1000 ⁇ g/ml) values of NR2 peptide.
  • a rapid assay of NR2 antibody assay is based on a latex agglutination technique.
  • the CIS-LA antibody assay employs triple concave slides with a built- in magnification device to detect the reaction visually, providing an immediate "yes” or "no" response.
  • serum samples are mixed with NR2 peptide coupled with colored latex particles and agglutination is visually detected through built-in magnification device within 2 to 5 minutes or is indicated using nephelometer.
  • the IgG concentrations in patient samples is expressed in ng/ml according to a calibration curve from a set of calibrators of 0-100 ng/ml and standards with "low” ( ⁇ 2.0 ng/ml) and "high” (6 ng/ml) values of NR2 antibodies.
  • EXAMPLE 3 EVALUATION OF NR2 ANTIBODIES IN ADULT SURGERY PATIENTS
  • Table 4 presents the results of a study undertaken in CPB patients to evaluate the capacity of pre-op NR2 Ab levels for predicting the likelihood of adverse neurological events. The results are presented for different cut offs of NR2 Ab levels in patient se4rum, and subdivided based on the presence or absence of a post-operative adverse event. Patients were deemed to have suffered an adverse neurological event if, within twenty eight days of the CBP surgery, the patient suffered from confusion, TIA or stroke were detected, based on an NIHSS score of greater than nine. Patients who did not suffer any neurological event were assigned to the "No Neuro Event" group.
  • Table 5 provides a detailed analysis of six different cut offs for NR2 Ab concentrations from 1.5 to 2.0 ng/ml, and demonstrates the efficacy of each cutoff at predicting adverse neurological events.
  • the event rate increases in the cut offs from 1.5 to 2.0 for both groups, it increases faster in the "Neuro Event" group. Therefore, the risk ratio increases significantly over the analyzed range with the best risk ratio corresponding to 2.0 ng/mL (ClinChem, 2003).
  • 96.0% (24/25) of patients with NR2 Ab concentrations >2.0 ng/ml preoperatively had neurological complications within 48 hours post-CPB, vs. only 5.4 % of patients with NR2 Ab concentrations ⁇ 2.0 ng/ml, resulting in a 17.9-fold increase (95% CI, 11.6-27.6) in the ability of the marker to predict postoperative neurological adverse events.
  • FIG. 1 presents three ROC curves based on data for the NR2 test.
  • NR2 Ab marker for TIA/stroke before CPB is illustrated in Figure 2.
  • concentrations of NR2 Ab in serum samples from patients with no adverse events remained under the cut off of 2.0 ng/ml at all time points during the study.
  • most patients with neurological adverse events had increased NR2 Ab values above the cut off of 2.0 ng/ml pre-operatively, and at 24 hours and 48 hours after the procedure.
  • NR2 Ab distributions among the patient group pre-operatively, 24 and 48 hours post-operatively showed that NR2 Ab can reliably reveal patients with neurological complications before surgery in patients with neurological complications while patients without neurological complications had NR2 Ab values under the cut off.
  • the NR2 Ab biomarker was sensitive to a decrease (i.e. worsening) in NIHSS scores at 24 h after surgery.

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Abstract

L'invention porte sur des procédés permettant de prévoir l'apparition d'événements neurologiques indésirables dus à une intervention chirurgicale. Parmi ces événements indésirables figurent par exemple les attaques, les délires et les accidents ischémiques transitoires. Ces procédés sont fondés sur la découverte selon laquelle les niveaux de peptides du récepteur de NMDA cérébral circulant et les niveaux des anticorps peuvent servir à identifier des patients susceptibles de souffrir d'un événement neurologique indésirable. L'invention porte sur des procédures diagnostiques permettant de mettre en oeuvre ces procédés de prévision, ainsi que des stratégies d'intervention afin de réduire le risque d'événements neurologiques indésirables dus à une intervention chirurgicale.
EP06719248.4A 2005-01-25 2006-01-24 Biomarqueurs ischemiques et utilisation associee pour prevoir des evenements neurologiques indesirables dus a une intervention chirurgicale Not-in-force EP1842064B1 (fr)

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US20060257943A1 (en) * 2005-01-25 2006-11-16 Cis Biotech, Inc. Ischemic biomarkers and their use to predict adverse neurological events from surgery
WO2008021408A2 (fr) * 2006-08-15 2008-02-21 The Trustees Of The University Of Pennsylvania Méthodes et compositions pour le traitement et le diagnostic de l'encéphalite auto-immune ou de l'épilepsie
WO2012051519A2 (fr) 2010-10-14 2012-04-19 The Johns Hopkins University Biomarqueurs d'une lésion cérébrale
US20140141458A1 (en) 2011-05-12 2014-05-22 The Johns Hopkins University Assay reagents for a neurogranin diagnostic kit
WO2013138509A1 (fr) 2012-03-13 2013-09-19 The Johns Hopkins University Protéines cérébrales et neurologiques citrullinées en tant que biomarqueurs de lésions cérébrales ou de neurodégénérescence
RU2667634C2 (ru) * 2012-06-05 2018-09-21 Нестек Са Способы диагностики хронического заболевания клапанов
WO2014160431A1 (fr) * 2013-03-13 2014-10-02 Health Diagnostic Laboratory, Inc. Procédé de détermination des antécédents d'accident vasculaire cérébral ischémique pour l'évaluation du risque actuel et le guidage de la thérapie
WO2015009907A1 (fr) 2013-07-17 2015-01-22 The Johns Hopkins University Dosage de biomarqueurs multiprotéiniques pour la détection et l'issue de lésions cérébrales
RU2668534C1 (ru) * 2017-07-18 2018-10-01 Общество с ограниченной ответственностью "ДРД" Диагностический набор реагентов для выявления хронических патологий мозга ишемического генеза
RU2686736C1 (ru) * 2017-11-20 2019-04-30 федеральное государственное бюджетное учреждение "Национальный медицинский исследовательский центр имени В.А. Алмазова" Министерства здравоохранения Российской Федерации (ФГБУ "НМИЦ им. В.А. Алмазова" Минздрава РФ) Способ выявления интраоперационных осложнений у нейрохирургических больных

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US20100173789A1 (en) 2010-07-08
CA2595263A1 (fr) 2006-08-03
WO2006081188A1 (fr) 2006-08-03
US20060257943A1 (en) 2006-11-16
EP1842064A1 (fr) 2007-10-10
RU2435165C2 (ru) 2011-11-27
EP1842064B1 (fr) 2013-12-25
US20080206793A1 (en) 2008-08-28
RU2007132194A (ru) 2009-03-10

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